The head of the Portland Community Health Center and her chief financial officer sat down last week to figure out which bills they could pay. They don’t have the money to pay all of them.

More than half of their patients are uninsured, up from about 30 percent a few years ago. The health center gets $725,000 from the federal government to help care for people in need, but the cost runs closer to $1.4 million.

In Lewiston, St. Mary’s Regional Medical Center budgeted for 5 percent of patients to be uninsured this year. Instead, so far, 8 percent are, and the hospital is about $2.3 million over budget on charity care and bad debt — money patients owe and can’t pay.

It’s on track to be $5.6 million over budget by year’s end.

At Tri-County Mental Health Services, at least 25 percent more uninsured patients are seeking help for mental illnesses and other issues than did last year.

“And those are just the people who end up showing up,” said Melissa Tremblay, director of clinical services for Tri-County. “How many others are floating out in communities, that are hanging on, determined not to incur another bill?”

Tri-County’s crisis programs have borne the brunt of those uninsured when they can’t “hang on.” The nonprofit’s stabilization unit last month ended its fiscal year $70,000 in the hole.

Hospitals, clinics and health care advocates say the problem is that Maine didn’t expand MaineCare, the state’s Medicaid program. And when the state started removing 22,000 people from the health insurance plan in January, it made the problem worse.

They believe Maine is seeing the effects of its two recent MaineCare decisions, and they include a burdened health care system, poor people without early medical care and hundreds of millions of dollars in federal funds lost.

However, Maine Department of Health and Human Services Commissioner Mary Mayhew points to another number: $800 million in taxpayer money that Maine won’t have to spend on expansion over the next 10 years.

The effect of not expanding from her point of view?

“We today are not staring at a sea of red ink in Medicaid,” Mayhew said.

‘Worrisome’

Medicaid provides health insurance to the poor, disabled and elderly. It is paid for through state and federal taxes.

Just over 300,000 Mainers are on Medicaid now, down from more than 360,000 in 2011.

As part of an effort to get all Americans access to health insurance, the 2010 Affordable Care Act — often referred to as “Obamacare” — required states to expand Medicaid to the very poor and penalized states that refused. In return, the federal government agreed to pay 100 percent of the cost for those new enrollees for three years, beginning in 2014. That federal contribution would phase down to 90 percent by 2020.

However, in 2012, the U.S. Supreme Court ruled the non-expansion penalty was unconstitutional. States could expand or not, as they saw fit.

As of last month, according to the Kaiser Family Foundation, 26 states and the District of Columbia have expanded. Twenty-one have not, and three are still debating the issue.

In 2012 and 2013, Gov. Paul LePage five times vetoed bills that would have expanded Medicaid in Maine. Despite various proposals during the last legislative session, that decision stood.

Maine is the only New England state not to expand.

In that time, Maine also made cuts and tightened eligibility requirements for MaineCare, dropping tens of thousands of people from the program. Most recently, effective Jan. 1, 2014, the state removed 7,439 childless adults and 14,661 parents who earned more than the federal poverty level. Parents may receive transitional health coverage for six to 12 months after removal.

If Maine had expanded, Mayhew said, the state likely would have seen its MaineCare rolls balloon from just over 300,000 to 400,000 people, a 33 percent increase.

“There are very difficult decisions and priorities that have to be made,” she said. “We simply don’t have unlimited resources, and we are focused on ensuring that those who most depend on the Medicaid program and the Department of Health and Human Services, that we are effectively meeting their needs.”

Because the Affordable Care Act had required states to expand Medicaid to cover people under the federal poverty level, the law made federal insurance subsidies available only to people who earned more than that. The expectation: very poor people would be covered by Medicaid, and others would get government help to buy their own health insurance.

But in Maine and other states that didn’t expand, those people under the poverty line — currently $11,670 for one person — don’t have access to Medicaid. And the law doesn’t make subsidies available to them to buy insurance on their own.

They are most likely to be uninsured.

“We are in a situation now where people who are the most vulnerable, most vulnerable from an economic perspective, do not have access to affordable health insurance. That’s a problem,” said Katie Fullam Harris, senior vice president of government and employer relations for Portland-based MaineHealth, the largest health care system in the state.

Hospitals, clinics and other health care organizations had hoped Maine would expand MaineCare for a number of reasons. They believe insurance will give the very poorest Mainers greater access to preventive care and regular care for chronic conditions, which would make people healthier and keep them out of expensive emergency rooms. They expected a more-insured population would help flatten their ever-rising charity care and bad-debt expenses.

And because the federal government helped pay for Medicaid expansion by trimming reimbursements for Medicare — the government health insurance program for the elderly and disabled — they hoped having more Medicaid patients would help offset the lower money they’d be getting from Medicare.

But because Maine didn’t expand, many say they are seeing the effects. Of the five large hospital systems surveyed by the Sun Journal, only one — Central Maine Healthcare in Lewiston — has not noted a significant change.

At Eastern Maine Medical Center in Bangor, bad debt and charity care are up $12.7 million in the first eight months of its fiscal year — a 40 percent increase over the same time last year.

St. Mary’s bad debt and charity care cost it $11.8 million in the first five months of its fiscal year, up from $9.6 million the same period last year, a 23 percent increase. Uninsured patients are up from 5 percent to 8 percent, while MaineCare patients are down from 20 percent to 17 percent.

At MaineGeneral Medical Center in Augusta, bad debt and charity care are up $2 million. That’s a smaller increase than in years past — it jumped $5 million between 2012 and 2013 — but the hospital has also lost $2 million in Medicare reimbursement and stands to lose more in the coming years.

Mike Koziol, senior vice president and chief financial officer for MaineGeneral, called it a “double whammy.”

“Medicare’s taking the money away and the anticipation is it gets shared back to the states that expand Medicaid,” he said. “We lost it in Medicare and aren’t getting the opportunity to get it back. That’s worrisome.”

It’s worrisome to MaineHealth, too. It expects that seven member hospitals and three affiliate hospitals — including St. Mary’s — will lose $323 million by 2019 in Medicare reductions not offset by new Medicaid patients.

Sebasticook Family Doctors, which serves just over 9,300 patients in five offices between Canaan and Dover-Foxcroft, saw 310 patients dropped from MaineCare, while just 60 patients got new private insurance through the Affordable Care Act. Between January and May, the health center’s MaineCare reimbursements fell $78,000, about 6 percent.

So many poor and uninsured patients have started seeking help buying medications that the health center recently had to hire a second person to run its busy drug-assistance programs.

DFD Russell Medical Centers serves 10,000 patients through locations in Turner, Leeds and Monmouth, more than 900 of whom have lost MaineCare coverage. For the first time in 12 years, the health center is running a deficit — $100,000 on a $4 million budget.

“We don’t anticipate being able to make that up,” said CEO Laurie Kane-Lewis.

Although health centers get federal funds to care for the uninsured, it comes as a block of money and doesn’t increase if the health center starts seeing more uninsured.

Proponents of MaineCare expansion say very poor patients, hospitals and health centers are among the first to be affected by the state’s MaineCare decisions, but they won’t be the last.

They believe the state stands to lose up to 1,000 health care and other jobs and is missing out on creating more than 3,000 new jobs by not expanding. They believe the state is losing out on more than $900,000 a day in federal funds, more than $350 million this year.

They say expansion would have given the state federal money to cover, among other things, inpatient hospital bills for jail and prison inmates, medication for low-income elderly Mainers, and mental health and substance abuse treatment for the poor. They also believe towns and cities would have benefited since their General Assistance programs often pay for medical care and medications — which wouldn’t be necessary if their very poor residents were covered by MaineCare.

“Those are dollars we could spend on something else if we did the expansion,” said state Rep. Peggy Rotundo, D-Lewiston. “The dollars that we’ve been spending as a state could go for something else — could go to lowering people’s property taxes, could go to more public education funding, more scholarship aid for students attending higher education in the state. Those are dollars that, as a poor state, we really need.”

‘Charting a course’

Opponents of expansion agree that Maine is a poor state.

They say that’s exactly why it can’t afford to expand.

“As much as it might be nice to be all things to all people, we are not in a financial position to,” said Joel Allumbaugh, director of the Center for Health Reform Initiatives for the conservative Maine Heritage Policy Center. “And when you continue to expand and sort of push aside the financial realities, not only is it the taxpayer who pays the burden, but I think in the end, the safety net ends up having an awful lot of holes in it, so even the most vulnerable end up paying the price.”

Mayhew, the DHHS commissioner, said the state’s MaineCare program is finally solvent after years of financial trouble.

“For the governor, and in my role overseeing this agency, it simply is impossible to prioritize and plan if you are constantly in a state of financial crisis and you are bailing out the boat,” she said. “If you are bailing out the boat, you are not charting a course.”

As of Jan. 1, MaineCare is no longer spending $27.2 million a year on health insurance for childless adults, according to DHHS. It’s also expected to save $18 million through 2016 because it tightened eligibility requirements for parents and is removing more than 14,000 from the insurance plan.

While the federal government has said it will pay 100 percent of the cost of new enrollees for three years, Mayhew said Maine won’t get that much. That’s because the state covered parents previously and the federal government won’t consider them new enrollees. So it’s saving money there, too.

Overall, Mayhew estimates the state would have spent $800 million over 10 years to expand MaineCare.

Some opponents of expansion say they’ve seen no impact from the state’s MaineCare decisions, and certainly not those described by health care organizations.

“Nobody’s come rushing to me,” said State Sen. Jim Hamper, R-Oxford, a member of the Legislature’s Health and Human Services Committee.

Others say they’ve seen an impact — a positive one.

Millions of dollars in MaineCare savings have already been earmarked to boost nursing home pay and to get people with intellectual and developmental disabilities off the state’s waiting list for services. They’re both dire needs the state had not been able to meet before, Mayhew said.

“That was done because we didn’t expand,” she said.

Not surprisingly, the two sides disagree with each other’s assertions.

Expansion proponents say Mayhew’s $800 million projected cost doesn’t take into account the savings Maine would see. They believe Maine would get about $62 from the federal government for every $1 it spends on expansion.

“Expansion would allow some people who are being covered with state funds to be covered with federal funds,” Sara Gagne-Holmes, executive director of Maine Equal Justice Partners, an Augusta-based legal aid group that advocates for the poor, said in an email. “Commissioner Mayhew, to the best of my knowledge, hasn’t taken these savings into consideration when she uses the $800 million number. Many, if not all, of the states that decided to expand Medicaid identified savings … to their programs.”

Maine Equal Justice Partners’ website features a running counter of the federal money Maine would have gotten with expansion starting Jan. 1. Adding about $11 each second, it stands at more than $184 million.

DHHS spokesman John Martins said the $800 million cost estimate is based on expenditures because any savings can’t truly be calculated.

“The savings estimates we have seen vary, are highly speculative and cannot be assumed,” he said in an email. “In fact, supposed projected savings in other states included slashing contracts for substance abuse and mental health providers to replace those services with Medicaid funds.”

Mayhew takes issue with the health centers’ claim that they don’t get enough money to pay for the poor and uninsured. They are paid, she said, a “significantly enhanced reimbursement rate.”

“Part of the reason for their reimbursement is that they are, in fact, supporting people without coverage,” she said.

And she said she’s “perplexed” by hospitals’ backing of MaineCare expansion since the state only recently paid them for years of back MaineCare debt and expansion would make that debt build again.

“We just finished paying off over $750 million worth of debt, Medicaid debt owed to hospitals that accumulated because the state had expanded the program and had not budgeted for the true cost of the program,” Mayhew said. “So I’m surprised that the hospitals who had been dealing with the debt would seek to advocate for further expansion.”

She believes the answer to covering Maine’s very poor isn’t spending state money to expand MaineCare; it’s getting the federal government to lower its subsidy line to cover people under the poverty level.

However, expansion proponents point out that there is no federal proposal to do that and Congress is unlikely to revisit the controversial Affordable Care Act or come to an agreement about such a change.

“Maine has the opportunity to address the access issue and that’s by doing Medicaid expansion,” Gagne-Holmes said. “And we can do it far more quickly and address the need far more quickly than Congress can.”

There is no Medicaid expansion deadline, so Maine could decide at any point to expand MaineCare. However, since the federal government will only pay for 100 percent of new enrollees through 2016, proponents say there is a ticking clock.

Various bills and compromise proposals failed during the last legislative session. Many proponents say the November election will tell them whether expansion has a chance next session, since a conservative governor and Legislature are more likely to keep things as they are and a liberal governor and Legislature are more likely to expand.

Hospitals, health centers and other health care organizations say they can deal with the situation short term, but they’re already considering what they’ll have to do if Maine continues to hold off expansion. For some, that may lead to layoffs or cutting services; for others it may lead to passing more of the cost of the uninsured on to the insured.

“It could mean a variety of things,” said Harris of MaineHealth. “It could mean that we charge more to our customers who have commercial insurance. It could mean that we have to reassess the availability of some of the community health programs that are so important in the communities that we serve. It could mean any number of things, and it will mean different things in different communities.”